Provider Demographics
NPI:1205125655
Name:SOVEREIGN MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SOVEREIGN MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAJJAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-791-4544
Mailing Address - Street 1:85 HARRISTOWN RD FL 2
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3329
Mailing Address - Country:US
Mailing Address - Phone:201-855-8446
Mailing Address - Fax:201-444-0350
Practice Address - Street 1:15-01 BROADWAY
Practice Address - Street 2:SUITE 1 & 3
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-791-4544
Practice Address - Fax:201-794-6970
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOVEREIGN MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-06
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7586205Medicaid
NJ002881Medicare PIN
NJ7586205Medicaid